Surgery* a network linking collagen and glycosaminoglycans (normal components of tissue matrix) in such a way

Transcription

1 Human Fibrin Glue Versus Sutures in Periodontal Surgery Giovan Paolo Pini Prato, Pierpaolo Cortellini, Giancarlo Agudio and Carlo Clauser Accepted for publication 2 September 1986 A fibrinsealing system consisting of symmetrical flap and graft procedures versus silk sutures in a splitmouth clinical trial was tested in 51 patients. Clinical parameters and operative times were recorded and compared. In clinical use, the fibrin glue provided quick hemostasis and adequate tissue adhesion on the whole inner surface of grafts or flaps. Its use saved remarkable amounts of time and made it easier to fix tissues in difficult areas. The time saved ranged from 3 to 19.5 minutes per procedure, and 1 to 8.5 minutes per tooth. The convenience of the fibrin glue was especially appreciated in pedicle flap procedures. Fibrin was first used as a hemostatic agent in and as a tissue sealant in Later, fibrinogen and thrombin were successfully employed to fix cutaneous grafts using fewer or no sutures.3 With the discovery of Factor XIII and the use of aprotinin as an antifibrinolytic substance, the fibrinsealing technique was substantially improved. In 1975 a fibrin sealant derived from autologous material plus aprotinin (Tissucol ) was used in peripheral neurosurgery.4 Since that time, fibrin glue has been used in many fields of surgery; it was first used to retain heterologous bone grafts in periodontal defects in and to fix periodontal flaps and grafts in It later proved to be effective in improving periodontal wound healing in both animal experiments and clinical trials.89 The fibrinsealing system is now available as a kit, consisting of 5 units: (1) lyophilized Tissucol (fibrinogen, Factor XIII, fibronectin, plateletderived growth factor (PDGF), Plasminogen, antiplasmins); (2) aprotinin; (3) thrombin; (4) calcium chloride; and (5) distilled water (Fig. 1). Lyophilized Tissucol. Fibrinogen and fibronectin are substances obtained as a cryoprecipitate of human plasma. Fibrinogen (high molecular weight protein: MW [molecular weight] 340,000) and fibronectin (high molecular weight glycoprotein: MW 440,000) are highly concentrated, about 30 and 10 times the normal concentration in human plasma, respectively.10 They make up the main part of the fibrin clot when acted upon by thrombin which is added at the very last moment. The fibrin clot provides hemostasis and forms Department of Periodontology, Dental School, University of Siena, Siena, Italy. 426 a network linking collagen and glycosaminoglycans (normal components of tissue matrix) in such a way that the adhesion of tissues occurs and fibroblasts, which have specific receptors for fibronectin, are attracted into the clot to produce new collagen.11 Factor XIII is a transglutaminase, an enzyme that plays an essential role in stabilizing links between fibronectin and fibrin in the clot and between the clot (fibrin and fibronectin) and collagen and glycosaminoglycans. Factor XIII also links antiplasmins to the fibrin clot. In this way Factor XIII gives molecular stability to the tridimensional reticulum of the fibrin clot. The concentration of Factor XIII in Tissucol is approximately tenfold the concentration in normal plasma.10 PDGF is a Polypeptide, which enhances fibroblast reduplication.12 Its concentration in Tissucol is higher than in normal plasma, even though it varies greatly in different preparations.10 Plasminogen is a glycoprotein (MW 90,000), which is transformed into plasmin under the effect of active thrombin. Plasmin, in turn, has a proteasic activity, which causes the lysis of the coagulum of fibrin and fibronectin. Plasminogen is associated with fibrinogen, but the plasminogen/fibrinogen ratio in Tissucol is 30 times less than in normal human plasma.10 Antiplasmins are macroglobulins which inhibit plasmin activity thereby reducing the rate of coagulum lysis. Aprotinin is a Polypeptide obtained from bovine lung, which inhibits fibrinolysis by linkage with plasmin on a 1:1 basis.13 Thrombin is a Polypeptide (MW 40,000) with enzymatic activity as a serinoprotease. Its main activity consists of the activation of fibrinogen and Factor XIII,

2 Volume 58 Fibrin Glue Versus Sutures 427 Number 6 syringe (Duploject ). (2) Time needed for the prepara tion, the sterilization and the storage of the instruments required for suturing. (3) Time needed to fix the flaps of grafts by using glue or sutures. (4) Persistence of bleeding 1 and 5 minutes after tissue positioning. (5) Stability of tissues 5 minutes after positioning when checked by gentle lateral pressure with tissue pliers. (6) Amount of Tissucol used in the procedure. Seven days after surgery, the time required to remove sutures was measured. The patients were also examined for edema, color of the tissues and erythema (around the emergence of sutures). At this examination the patients were asked to report any differences in pain between the two sides. Fourteen and 21 days after surgery, the tissues were reexamined clinically for differences between test and Figure 1. The Tissucol kit. Table 1 Types of s Performed with the Use of Tissucol on One Side (Test Side) and Sutures on the Other Side (Control Side) Number of Number of teeth patients (each side) Free gingival grafts () sliding flaps () Modified Widman flap () Apically positioned flaps () which in turn leads to the formation and stabilization of the coagulum. The speed of coagulum formation is directly related to thrombin concentration. The kit provides two different concentrations: 400 or 500 NIH (National Institutes of Health) units for slow or quick coagulation, respectively. Calcium chloride is an ionic compound which is essential for thrombin activity. The combined effect of the substances contained in the kit provides prompt hemostasis, prolonged stability of the coagulum with firm and persistent adhesion, and quicker wound healing.8,9 The aim of this study was to test the fibrin glue versus silk sutures from the biological and clinical standpoints. control sides. The time intervals half minute. were approximated to the nearest Fixing Techniques. On one side (control side), chosen random basis, Ethicon 40 silk sutures were used; on the other side (test side) the fibrin glue was employed. Tissucol kit 0.5 or 1 ml was prepared selecting thrombin 500 NIH and aprotinin without any addition of distilled water in order to maintain the highest conon a centration. The steps of preparation were as follows: all the placed in a special thermostat set at 37 C coupled with a magnetic shaker (Tissutherm ). Distilled bottles were discarded. After preheating (7 minutes), aprotinin was transferred into the Tissucol bottle by a standard syringe; then the bottle was placed in the shaking device until the mixture appeared quite homogeneous (5 to 10 minutes). Meanwhile the content of the ampule with calcium chloride was transferred into the thrombin bottle. water and thrombin 4 NIH were MATERIALS AND METHODS Clinical Trial. Fiftyone patients, aged 9 to 63 years, 22 males and 29 females, being judged suitable for symmetrical flap or graft procedures, were selected for the study over a period of 3 years. The patients were required to show proper plaque control for at least 3 months preoperatively. The procedures performed in these patients are reported in Table 1. Data Collection. At the time of surgery, the following data were collected. ( 1 ) Time needed for the preparation of Tissucol including each phase: mixing the components, heating and agitation, preparation of the special Figure 2. A. Duploject syringe. B. A drop of the final solution applied between a graft and the recipient area. is

3 428 Pini Prato, Cortellini, J. Periodontol. June, 1987 Agudio, Clauser Finally, equal amounts of reconstituted Tissucol and thrombin were drawn up in two identical disposable syringes, which, in turn, were mounted on a device (Duploject) that allows for simultaneous application of equal amounts of the two solutions through the same blunt needle. The final solution was applied between the graft or the flap and the surgical bed (Fig. 2). Soon after the application of the fibrin glue, the tissues were positioned; 5 to 10 seconds were allowed to change the position of tissues. Thereafter, the tissues were kept in position by the gentle pressure of a wet gauze for 20 to 30 Both the components of the solution, once initiated, remain active for at least 4 hours and can be used for different patients. After each application, the needle must be replaced, not only for obvious hygienic reasons, but also because the fibrin clot itself obstructs the needle. One case is shown in Figure 3. Table 2 Time Needed to Prepare Tissucol Time Phase Minimum 7 Heating Mixing 5 Shaking 2 Preparing syringes Clinical Trial. The time needed for the dental assistant to prepare the fibrinsealing system ranged from 10 to 16 minutes and is reported in Table 2. The time needed to wash, sonicate and pack suture holder, scissors and pliers ranged from 9 to 10 minutes. Overall Fibrin glue 1 Sutures 315t Time per tooth , free gingival graft; pedicle, pedicle sliding modified Widman flap;, apically positioned flap, t B. On the right side the fibrin glue was used to fix tissues, while on the left side 40 silk sutures were used. timet procedure flaps;, Table 4 Amounts of Tissucol Each Patient Figure 3. Preoperative (A) and postoperative (B) views of the lower anterior teeth of a patient who underwent a modified Widman flap 7 Table 3 Time Needed to Fix Tissues RESULTS Maximum Used, Approximated to the Nearest 0.1 ml for Total amount Amount per tooth The sterilization cycle in the autoclave required 20 minutes. The time needed to store instruments or to open the Tissucol kit was negligible (less than 1 minute). The time needed to fix tissues by fibrin glue or by sutures is reported in Table 3. The time reported to fix tissues does not include the time needed to compress flaps and grafts in order to avoid hematomas (with sutures), but it does include the compression time needed to allow for gluing, to avoid dislocations (with the fibrin glue). In each case, bleeding subsided definitely more quickly after the application of Tissucol than after suturing; accurate measurements of the residual bleeding were not performed. In one case only, bleeding persisted 1 minute after suturing. Tissues were always attached to the underlying layer 5 minutes after the application of the glue, while the tissues treated by free grafts were still movable 5 minutes after completion of suturing.

4 Volume 58 Number 6 Fibrin Glue Versus Sutures 429 The amount of Tissucol used averaged 0.1 ml per tooth on each side (0.2 ml in cases of flap procedure on both buccal and lingual aspects) (Table 4). At the examination 7 days postoperatively, a red halo around sutures was usually evident on the control side. Edema was negligible on both sides. Most patients did not notice any subjective differences between the two sides although discomfort was often noticed during the removal of sutures. However, three patients reported greater pain on the control side, with one reporting pain on the experimental side. The time required to remove sutures is reported in Table 5. Table 6 shows the differences in the chair time required when the sutures and the fibrinsealing system were used in symmetrical procedures. Suture times include their removal. Clinical reexamination of the patients 14 and 21 days postoperatively did not reveal any meaningful differences between test and control sides. Figures 4 and 5 show the healing after 14 and 60 days, respectively, of the patient shown in Fig. 3. Figure 4. Healing after 14 days (same patient as in Fig. 3). DISCUSSION fibrinsealing system in the clinical 40 silk sutures were used as a contrial, noncapillary trol since the latter is the usual means of fixing tissues in periodontal surgery. Synthetic adhesives (cyanoacrilates) have been discarded because of toxicity, stiffness and lack of acceptance by clinicians. However, from a biological standpoint, the fibrin glue seemed both innocuous and effective, also bringing about early wound healing. This behavior is substantially different from that produced by the use of cyanoacrilates, which affect wound healing negatively. Resorbable sutures are sometimes used in periodontics, but they are known to cause To evaluate the Table 5 Time Needed to Remove Sutures Overall time 5 14 l6 2 Time per tooth Tableó Summary of the Chair Times for Fibrin Glue Versus Sutures Overall time Time per tooth Figure 5. Healing after 60 days (same patient as in Fig. 3). responses.14 Monofilament nonabsorbable synthetic sutures give the least tissue reaction,14 but they are extremely awkward for routine use in periodontics. To fix flaps or grafts by fibrin glue does not require any special skill; it is sufficient to pour the glue into the involved area using the double syringe. The glue quickly adheres to tissues. The amount of Tissucol needed to fix tissues averages less than 0.1 ml per tooth on each aspect (buccal or lingual). There is a trend toward an inverse relation between the number of teeth involved and the amount of Tissucol per tooth. However, even for procedures on a single tooth, one or two drops (less than 0.1 ml) are usually enough. If some glue drops away from the operative field, it is quite harmless and can be removed easily by a gauze. Tissucol and thrombin, once reconstituted, remain usable for 4 hours, which allows the use of the same kit for the same or different patients. For safety, it is necessary to change the needles after every application and because coagulation occurs in the needle itself and can start the coagulation of the remaining solution inside the syringe. Bleeding, if any, stops soon after the application of the fibrin glue making it possible to position flaps or strong inflammatory

5 430 Pini Prato, J. Periodontol. June, 1987 Cortellini, Agudio, Clauser adhesion of tissues requires 3 minutes under finger a wet gauze to complete the chemical links inside the clot. With the highest concentration, minimum pressure is enough to obtain stability. The concentration of aprotinin can be varied in order to obtain the desired persistence of the fibrin coagulum if the different fibrinolytic activities of the various tissues13 are taken into account. In fact, the persistence of the coagulum should not exceed a few days; at the end of a week, remnants of the coagulum should hardly be found histologically. According to previous experimental work, this result can be accomplished using aprotinin at full concentration9; indeed, the human gingiva is reported to display high fibrinolytic activity.15 To summarize data, ranges and medians were chosen because of the small size of some samples, namely the free gingival graft () and pedicle series. No statistical significance test was reported because the two techniques are obviously different and the results can be interpreted directly. The true significance for the office routine can better be assessed from the reported data. In order to read the results correctly, one should keep in mind that overall times were approximated to the nearest half minute. The time saved by gluing is underestimated because the records of suturing time did not include the time spent to compress tissues after suturing, while the compression time for gluing was recorded. Since the compression time after suturing varies greatly according to the operators habits, computation time has been left to the reader; 2 to 3 minutes should be added to the suture time for each operation. Conventional suturing provides only a marginal fixation, while the fibrinsealing system makes the tissue adhere on its whole surface. This total adhesion, together with fast hemostasis, helps in preventing displacement and hematoma formation. The fibrin glue provides tissue fixation virtually without any injury, while suturing causes mechanical stress. Such trauma is potentially harmful to tiny flaps especially when the blood supply is critical in the postoperative period, as in root coverage procedures. It is also worth noting that it is much easier to fix flaps and grafts in difficult areas (e.g., upper molars, lingual aspect) using the glue. The greater ease with which this is done reduces operative time and also makes the procedure less uncomfortable for the patient pressure with histologie section perpendicular to a suture line. The taken out 2 hours after suturing (H & E, original magnification xloo). B. A similar section from a specimen taken 3 days after surgery. C. Another section 7 days postoperatively. Figure 6. A. A specimen was grafts precisely. Both hemostatic and adhering effects can be modulated using thrombin in different concen trations: 4 NIH thrombin allows 20 to 30 seconds to adjust flaps or grafts before clotting. Five hundred NIH solution reduces operative and clotting times and is especially useful with small flaps since positioning of tissues must be accomplished in less than 5 to 10 With the lower concentration of thrombin, full and the surgeon. There are further advantages on the patients side: the removal of sutures is sometimes annoying or even painful. Some patients, especially children, felt more comfortable on the sutureless side in the days after surgery. The only patient who felt worse on the test side had had an extreme apical positioning of tissues on that side where a small bony area was uncovered; this could well account for the additional discomfort. The appearance of tissues 1 week postoperatively was

6 Volume 58 Number 6 Fibrin Glue Versus Sutures 431 consistently better on the test side; this fact can be accounted for both by direct effect of Tissucol on wound healing8 and by less trauma during fixation. During the clinical trial no postoperative failure or complications occurred on either side. It should be pointed out that conventional periodontal surgery was performed on both sides, without any attempt to test Tissucol in especially critical procedures or in patients with coagulation problems. Because of this, potential advantages of the new technique could have been overlooked. All of the results of this comparative study involving more than 200 periodontal cases confirmed our opinions that fibrin glue could be used successfully in periodontal surgery. The overall convenience of the use of the fibrinsealing system should also be evaluated on the basis of its cost and benefits. On one hand the thermostat and kit are expensive; on the other hand, the use of the glue saves time during surgical procedures and avoids time wasted in suture removal. Moreover, the fibrinsealing system saves the cost of preparing, sterilizing and storing instruments, as well as the cost of the sutures themselves. Tissucol is a cryoprecipitate of human plasma, but vapor heating during manufacturing prevents any risk of transmitting AIDS. In spite of the widespread use of Tissucol in Europe, no evidence of transmission of infectious hepatitis has been reported at this time. CONCLUSIONS 1. The fibrin glue is easier and quicker to use than sutures. 2. The fibrin sealing system provides better early hemostasis and a complete adhesion of the whole surface of the 34 tissues to the underlying layer. 3. Sutures cause inflammation around themselves, while Tissucol enhances early wound healing. 4. The fibrinsealing system is effective as a means of fixing tissues after periodontal surgery. Editors Note: While the Tissucol system is widely used in Europe, it has not been approvedfor use in the United States at the time ofthis writing. REFERENCES 1. Grey, E. G.: Fibrin as a haemostatic in cerebral surgery. Surg Gyn Obstetr 21:452, Young, J. Z., and Medawar, P. B.: Fibrin suture of peripheral nerves. Lancet!: 126, Cronkite, E. P., Lozner, E. L., and Deaver, J. M.: Use of thrombin and fibrinogen in skingrafting. J Am Med Assoc 125: 976, Matras, H., and Kuderna, PL: Gluing nerve anastomoses with clotting substances. Trans 6th Int Congr Plastic Recensir Surg 134, Bosch, P., Lintner, F., Arbes, PL, and Brand, G.: Experimental investigations of the effect of the fibrin adhesive in the kiel heterologous bone graft. Arch Orthop Surg 96: 177, Pini Prato, G., and Masi, P. L.: Nuova tecnica di sintesi tissutale senza sutura. Min Stomatol 31: 755, Bartolucci, E. G., and Pini Prato, G.: Preliminary observations on the use of biologic sealing system (Tissucol ) in periodontal surgery. J Periodontol 53: 731, Pini Prato, G., De Paoli, S., Clauser, G, and Bartolucci, E.: On the use of a biologie sealing system (Tissucol ) in periodontal surgery. Int J Periodontol Rest Dent 4: 49, Pini Prato, G., De Paoli, S., Cortellini, P., et al.: On the use of a biologie sealing system (Tissucol ) in periodontal therapy. II. Histologie evaluation. Int J Periodont Rest Dent 3: 33, Seelich, T., and Redl, H.: Das Fibrinklebesystem biochemische grundlagen der Klebemetode. Dtsch MundKiefesGesichts Ctò(suppL) 3: 22, Pena, S. D. J., and Hughers, R. C: Fibronectinplasma membrane interaction in the adhesion and spreading of hamster fibroblasts. Nature 276: 80, Rutherford, R., and Ross, R.: Platelet factors stimulate fibroblasts and smooth muscle cells quiescent in plasmaserum to proliferate. J Cell Biol 69: 196, Dingers, H. P., Redl, H., and Kuderna, H.: Histopathologie nach fibrinklebung. Hefte Unfallheilkd 148: 792, Scohen, F. J.: Surgical sutures. New Phys 25: 40, Pini Prato, G. P., Cortellini, P., Agudio, G., et al.: Lattività fibrinolitica della gengiva umana: nota tecnica. Mondo Odontostomatolri: 39, Send reprint requests to: Giovanpaolo Pini Prato, viale Matteotti, 11, Firenze, Italy.